Restoring Teeth with Implants

I had a post a while back about implants and want to follow up on that. I have a couple implant cases and wanted to share the process of restoring the implant.  As I've explained to patients at school and friends, a dental implant is basically the "root portion" of the tooth. The titanium implant is placed, and allowed to integrate with surrounding bone. Once the implant is deemed integrated and stable, then we can restore it with a crown. At UB as pre-doctoral students, we do not do immediate loading cases, but this is possible in some cases.

After 3-6 months, once the implant has osseo-integrated (bone has grown into the threads of the implant) we can begin the restorative phase. 

I. Data Gathering/ Treatment Planning

This case involves a patient who is seeking implant restoration of tooth #5. No significant medical history. 

Dx cast occlusal 

Dx casts lateral

Dx wax up #5 occlusal

Dx wax up #5 lateral

The process began with diagnostic impressions and treatment planning. There was adequate interocclusal and mesio-distal space for implant restoration. A 4.2mm Straumann Narrow Collar (NC) SLA Implant was selected for placement by the surgeon. A surgical guide made from TRIAD material and a radioopaque cylinder was fabricated to assist the surgeon in placing the implant with the correct angulation. This is important because implants must be at least 1.5mm from adjacent teeth and if implants are placed next to each other there should be at least 3 mm of bone between them.The patient returned for a try-in appointment where one periapical radiograph was taken to ensure correct angulation with regard to adjacent teeth roots, and to ensure the guide fit passively and completely. 

TRIAD surgical guide

Next, the surgeon scheduled the patient for implant placement. A full thickness flap technique was utilized and the guide was used for initial osteotomy.  The implant was placed without complication. The patient was then allowed to heal for 4 months. Upon follow up with the surgeon, the implant appeared to have integrated with bone well, and I was notified that restorative phase of treatmnt could begin.

The patient was appointed for a closed tray implant impression. Prior to the appointment an impression post, cap and analog were secured from Straumann. A custom tray was also fabricated for the impression making. 

II. Soft Tissue Model Fabrication

Straumann Implant components

TRIAD Custom Tray

At the impression making appointment, the patients vitals were taken, and the procedure was explained to the patient. The healing cap was removed from the implant, gingiva was healed very well. The impression post was then inserted and screwed into the implant so that the arrows on the post were oriented bucco-lingually. The patient was given a cotton roll to bite on posterior to site #5 to prevent damage to opposing teeth from the impression post. A periapical radiograph was taken to ensure complete seating of the impression post. Once complete seating was confirmed, the yellow impression cap was placed onto the impression post, and the impression was made using Aquasil Light and Medium Bodied Polyvinyl Siloxane impression materials. 

Closed Tray fixture level impression 

The impression was inspected and decided to be adequate. The impression post and cap come out with the impression. The post is unscrewed, and in it's place the implant analog is screwed into the impression.

This impression was used as a soft tissue model. In the lab, separator was applied on the impression material around the implant analog. Gingifast was then applied around the implant to simulate the gingiva and help us plan how we will develop emergence profile in the gingiva. Separator was then applied on the Gingifast after 2-5 minutes once the material cures. Separator is applied twice because we do not want the gingifast sticking to the impression, or to the stone. The impression was then poured using Jade Stone. 

Creating soft tissue cast

Soft tissue cast

III. Provisional Abutment/Crown Fabrication 

This soft tissue cast will now be used to select our provisional abutment, fabricate a custom abutment  if necessary and a provisional crown. Provisionals will help us develop the gingival emergence profile before the definitive crown is cemented. 

The next step was to secure a provisional abutment from Straumann. The components arrived in about a week.

Provisional abutment and screw

Soft tissue cast, provisional abutment & Straumann screwdriver

The implant analog was unscrewed from the cast and we were left with a cast replicating what is present in the mouth. We can now see the gingival height and shape we will be working with. We've learned a number of times that an implant is not a tooth. It's actually nothing like a tooth. It is ankylosed, lacking a periodontal ligament, and emerges from the gingiva in a circular shape. With this procedure we are hoping to achieve a more tooth-like gingival architecture surrounding the eventual crown. The provisional abutment here is screwed into place. And any undercuts on the mesial and distal of site #5 have been blocked out with wax.

Next this provisional abutment was etched, to enhance the bond of the PMMA acrylic. 

The abutment was then marked and cut down so that my template could be used to fabricate a provisional crown. 

The access to the screw channel needed to be maintained so that I would be able to retrieve the provisional crown. A hole was made in my vacuum-formed template to accommodate the screwdriver at the correct angulation. The provisional stump was also trimmed further to accommodate my vacuum-formed template of #5

This step was particularly tricky. . The PMMA was then mixed to the "doughy" state and the template filled around the screwdriver. The template-screwdriver apparatus was then brought to the cast and seated and re-seated a number of times as the PMMA set so that the crown would not lock into any undercuts that may have been missed during the block out.  The seating and reseating was done by basically screwing and unscrewing the provisional into the implant analog a number of times gently. 

The provisional eventually self cured and was removed from the vacuum-formed template, trimmed and polished with Acrylustre. The Gingifast was trimmed minimally into an oval shape buccolingually which will allow the provisional to create the emergence profile we are looking for in the mouth. The surface of the provisional contacting gingiva was highly polished to discourage any plaque accumulation.

Occlusion was checked with the opposing cast and we are ready for try in!

Indian Health Service - Seneca Nation

Little article for an ASDA Buffalo publication -

“Opportunity, adventure and purpose” - this is the tagline of the Indian Health Service’s (IHS) dental externship and after this summer I know why. IHS offers an incredible opportunity for pre-doctoral students to serve in a culturally diverse and unique setting. Located about 40 minutes from UBSDM, the Cattaraugus Indian Reservation Health Center is one of two primary medical and dental facilities for the Seneca Nation.  The dental facility features digital radiography, electronic health records, a variety of materials and excellent staff. The externship is a great way to experience dentistry, and give back to an underserved population

As the “Keeper of the Western Door” the Seneca people have strong sense of community and culture. From the signs written in Seneca language, to patients sharing stories of their family lineage, serving this population proves to be most rewarding.   For those interested in public health dentistry, or experiencing a different patient population, the Seneca Nation is a great place to start!

Remote Area Medical (RAM) - Scott County, Tennessee

RAM is a non-profit group who operates solely under donations of time and support to provide medical care to rural areas in the U.S. mainly in Tennessee, and disaster affected areas of the world.

Scott High School, where clinics were held

RAM trucks unloading supplies

I just returned from my first ever RAM trip and it was nothing short of exhausting, inspiring and incredible. I made the 10 or so hour drive down with a few other classmates and we stayed at a church a few miles away from Scott County High School, where the clinic was held.

Friday night was spent settling in but clinic started early Saturday morning at 6:45am. By the time we arrived RAM volunteers had the dental clinics in full swing and patients registered and waiting, while others were already being seen. We were briefed on the way the clinics run, how we review the patient's form, retrieve supplies, complete treatment and complete what was accomplished before handing the patient their form to check out with.

Southern hospitality

Church where we were lodged

I had an amazing assistant Paula, whom stuck it out with me all day Saturday. We started off doing restorative, rebuilding teeth with composites and amalgams. We later switched over to extractions. While the patients were all tremendously grateful and pleasant, the underlying despair was ever present. Patients had waited all night, and toward 5PM, all day to be seen. Many I spoke with talked about their need to care for their families, or had other situations which made dental care close to impossible for them to access. While their situations were desperate, the ability to relieve pain, and restore dentitions that may have soon been lost was incredibly rewarding. One conversation that will stay with me was with one patient we completed a few fillings for who was very phobic and had not been to a dentist in many years. She expressed concern about a small cavity where a previous filling was lost, and said she was scared she would just have to wait to get it pulled. I was taken aback since the cavity was quite small and was easily restored. But the patient explained that sometimes we are so concerned with caring for our loved one that our own bodies are neglected and there may not be resources to care for ourselves. I felt for her and told her it was wonderful meeting her and she expressed her grattitude before heading off with her grandson.

RAM in full swing

The trip really made it clear to me that there's so much to still be done right here in the U.S. to improve oral healthcare. But oral healthcare is so closely related to mental and physical health. I don't doubt the involvement of drugs and mental unrest in many patient's destroyed dentitions.

Sunday Clean-up 

Sinus Elevation Site #3

With this spring extension marking the start of fourth year, I've been in the clinic 5 days a week, and getting some cool exposure to procedures we've learned about. I'll probably be writing more about procedures from this point on as we'll hopefully be doing lots of dentistry from here on out! Since I had some open appointments this week I was able to fit in observing a sinus lift in the implant clinic.

Sinus lifts are necessary in certain cases when a patient wishes to replace a tooth with an implant in the posterior maxilla. The maxillary sinus sometimes extends lower down than we'd like and to avoid placing the apical portion of the implant into the sinus, the sinus lift procedure is necessary prior to implant placement. 

Heres a couple informative graphics I found online which clearly show what's going on. This patient is also missing teeth they wish to replace in the posterior left maxilla. The sinus has undergone pneumatization which leaves the dentist with little bone to work with. Through a sinus lift procedure they were able to place three implants to restore those teeth 

[http://www.capedental.com/2013/sinus-lift-and-implants/]

[http://www.capedental.com/2013/sinus-lift-and-implants/]

The patient today however was a single 10mm x 4.8mm implant placed in site #3. The patient had nonsignificant medical history and the tooth was lost due to caries some time ago. There was 8mm of bone present and therefore needed a lift of 2mm to place the implant. 

Initially the patient was anesthetized with an infraorbital block, posterior superior alveolar injection and a greater palatine injection with 2% lido with 0.034mg epi per carpule. Once anesthetizd, the patient was draped and scrubbed extraorally with an alcohol swab, and intraorally with a chlorhexidine saturated sponge. 

The initial incisions were intrasulcular around teeth #2 and #4. The second was a crestal incision and a full thickness flap was reflected to expose the alveolar bone. The osteotomy was made using the Straumann kit drills to a depth of 7mm, and a width just shy of 4.8mm leaving 1mm of bone between the osteotomy and the Schneiderian membrane of the sinus. The sinus was then lifted using osteotomes and a mallet. Osteotomes were placed in the osteotomy site and lightly tapped to lift the sinus. Progressively larger osteotomes were used to complete the osteotomy. Two pieces of resorbable collagen membrane were placed at the apical extent of the osteotomy before the implant was placed. This membrane will resorb within 6-8 weeks. 

The implant was then placed at a speed of 35RPM into the osteotomy site to a depth of 10mm so the implant was placed at bone level. The final insertion of the implant was completed using hand wrenches rather than the motorized drill. The healing cap was placed and flaps re-adapted to the alveolar bone and three teflon interrupted sutures were placed. 

Cool experience overall. Post op radiograph looked great and hopefully all goes well with the restorative phase!

ECHM: Dedication/Ribbon Cutting

UB ECHM Team w/ dental director Dr. Nguyen at center

Friday was big. Not only were we in the midst of our final, final exam weeks ever, the Erie County Health Mall was officially dedicated and declared re-opened. While the dental clinic will not be seeing patients until June 2nd, our other partners in the building will be fully functional soon.

Ribbon Cutting!

Richie Ross representing our student team

Dr. Michael Glick, dean of UBSDM 

D3 Spring - Mid Semester Review

We're rounding up what was 3 weeks of midterms this week and finishing it off with a well deserved Spring break. I've personally been much less busy this semester compared to last, as I completed a few removable cases that are currently healing, and my implant cases are currently awaiting placement and healing. Nonetheless, the learning never stops as we have a quite a few classes to keep us busy. In most however, we seem to be going into a little more detail, and focusing on the clinical aspects of practice, while classes are also re-emphasizing important points that have been covered before. Luckily, we have one lab class in orthodontics that has been great.

Our lab instructor Brian Willison, is a renowned lecturer and orthodontic lab technician who is incredibly talented and helpful. Our first project in the top photo involved bending wires to a pattern on a piece of paper. The "snowman project" was given also as a supplemental project to get us used to bending wires around a model. The next project was a little more involved- bending wires to create clasps for a partial removable denture. We're currently in the midst of working on an active plate to reposition displaced maxillary lateral incisors that makes this project look terribly simple. But the first tim around, anything would be challenging. Its great learning through these projects because when we see patients in need of interim appliances, its great to know we are capable of creating something quickly and efficiently for them.  

Our midterms "month" comprises exams in: Special Needs Dentistry, Geriatric Dentistry, Surgical Periodontal Therapy,  Orthodontics, Anesthesia and Pain Control, Fixed Prosthodontics, Removable Prosthodontics and a take home exam in Temporomandibular Disorders. I don't think I've ever had this many exams, or been so mentally taxed, but it's going to be wonderful when we're through. 

Outside of this dental realm, I've managed to sign up for an online class in Social Entrepreneurship through the Social Work school here at UB. I caught sight of this opportunity via email shortly before my trip to Haiti and felt it was something I was meant to do. So far it's been a very enlightening experience, hearing the ideas and views of others who seek to improve society in their own special ways. As we're learning currently about the different models of non-profit and for-profit enterprises, it makes me feel as though any school hoping to breed dentists interested in community service should encourage students to take a class such as this. The class has definitely changed my perspective on non-profits and makes the prospect of giving back through an enterprise of my own seem more feasible. 

That's about it for now. Back to the books. 

Published!

I had great expectations for this month's issue of ASDA News and rightfully so! I submitted my first book review for the publication back in December and it's been published! Pretty excited. I really want to do this again. Here's the text:

If there has ever been a time to blaze your own path, take risks, and change the way we think, now is the time. In Linchpin: Are you Indispensable? Seth Godin inspires his readers to pursue their passions wholeheartedly. He asserts that this passion is not simply an option, but a requirement for success in a changing society. The former model of being trained to simply do a job is obsolete. Professionals as well as nonprofessionals are being called to solve unique problems. As dentists, we must not only be manually and intellectually adept, but also serve as team builders, community leaders, and more. The way I see it, the nature of the profession demands that we become linchpins. 

A linchpin is a pin placed through an axle that keeps the wheel in position while it rotates. Godin defines a linchpin as one who successfully combines passion with art. Great organizations and ideas arise from these types of people. Through historical anecdotes of his own life, artists and corporate leaders, Godin illustrates that we are all artists with gifts to share; and to not share them would be a disservice to society.

He describes art as, “the ability to change people with your work, to see things as they are and create stories, images, and interactions that change the marketplace.” We already see this in dentistry today where dentists are challenged to provide care in the face of barriers such as anxiety, or costs.  The innovation and evolution of sedation dentistry has changed the marketplace and brought care to those who may have been emotionally out of our profession's reach before . Moreover, dentists in Michigan are demonstrating linchpin qualities in reaching the underserved. They‘ve created a system where community service can be done in exchange for dental care. Dental related ER visits are down and patients who previously could not afford dental care, now have dental homes.  

All health professionals are required to do the “emotional work” that is one of the tenets of Godin’s linchpin. Godin rejects the idea of scripted courtesies and calls for genuine compassion in our interactions. He explains how JetBlue built their brand not by training attendants to be friendly, but by seeking out individuals with the qualities they wanted and encouraging them to make connections with customers.  “ The act of giving someone a smile, of connecting to a human, of taking initiative, of being surprising, of being creative, of putting on a show…we do for free all our lives.” These “emotional gifts” as Godin puts it, are essential to creating value in our interactions.

Linchpins are those who have conquered the “lizard brain”.  This lizard brain, better known as the amygdala plays a key role in anger, arousal, hunger and fear. Virtually all dental students can relate to the excited anxiety of our first operative procedure. Imagine the fear of failure in starting your own practice. We are wired to resist; but with some effort, we can be rewired. The first step is the decision not to feed your anxiety. Godin explains how simply acknowledging it, but not rationalizing the feeling eventually leads to its dissipation.  Realize anxiety is practicing failure in advance, it doesn’t protect us or help accomplish but rather inhibits progress. Banish procrastination, as this is the lizard brain keeping us stuck. Develop a “posture of challenging the resistance”; good habits can be fashioned just the same as we fall into bad ones. Conquering the resistance comes back to believing in your cause, “When you set down the path to create art...the path is neither short nor easy. That means you must determine if the route is worth the effort. If it’s not, dream bigger.”

Most importantly, Godin reaffirms us that,  “All of these attributes are choices, not talents, and all of them are available to you.” As future health care professionals we have the incredible opportunity to create valuable change in those around us. Linchpin encourages its readers to view your art as a gift; to be generous, bold, and creative. Health care is changing, and “Our passion for contribution and possibility, the passion we’ve drowned out in school and in the corporate world – that’s the only way.”

Surgical Guide Techniques - Triad & Vacuuform

I was fortunate enough to have an implant case this semester. At UBSDM, we're involved in every aspect of the implant treatment, from it's placement to it's final restoration. As we were taught in pre-clinic, implant treatment involves a team of practitioners and careful planning and communication is essential.

The Surgical Guide is a tool made by the restorative dentist and [hopefully] used by the implant surgeon to place the implant in the location dictated by the restorative dentist. Once placed properly, the restorative dentist can then select an abutment and crown to finish the restoration. The surgical guide is used in treatment planning as well. Once completed, the patient is brought back, the guide tried in and a radiograph (CBCT or PA) is taken to assess the angulation and planned placement of the implant.

At the initial evaluation, we take a medical and dental history, and address any chief complaints. The implant treatment planning starts here, where we take the necessary radiographs to assess bone, alginate impressions, a facebow and bite registration so that we can mount the diagnostic casts.

So this implant is being planned for position #29. 

[Left]So here's the cast of the lower arch. 

[Middle]We first do a diagnostic wax up of the tooth, with proper embrasures and [Right]occlusal contacts. Next, an alginate impression is taken of the cast with the wax up so that we have a template from which to make the vaccuformed surgical guide. 

[Left]Here's the duplicated cast, trimmed and after the vaccumform was made. The hole in the tongue space helps the template better adapt. The template is then removed from the cast somewhat carefully. The cast won't be needed anymore so it shouldn't be concerning if it breaks, but the template should be handled carefully.

[Middle] Here's the trimmed guide after removal from the cast. The area around #29 is trimmed to the gingival margin, however around all other teeth the guide is trimmed to half the occluso-gingival height of the tooth. The guide should seat on the original cast without rocking. 

[Right] Next we need to fill position #29 with a radiopaque material so that when the guide is tried in the patient's mouth, we can assess the angulation of the implant. Barium sulfate is combined with PMMA and the tooth to be restored is filled in.

A hole is then made to accomodate the metal cylinder. The vacuuformed template with PMMA and barium Sulfate is slide onto the cast, and the cylinder is secured into place with super glue. I'll need to get a photo up of the finished thing. But here is a finished TRIAD guide:

 

So with these guides the surgeon can make a pilot hole at an angulation that has been previously evaluated radigraphically. After the implant is placed we'll be going through the impressioning techniques to restore!